*Purpose: Determine risk factors associated with micafungin non-susceptible invasive candidiasis (IC) in solid organ transplant (SOT) recipients

*Methods: We conducted a retrospective study of SOT patients with IC due to micafungin non-susceptible Candida (cases) matched to SOT recipients with micafungin susceptible IC (controls). Multivariable analysis was performed to determine risk factors associated with micafungin non-susceptible IC

*Results: Eighteen cases of micafungin non-susceptible IC were identified, and 54 controls were included. Small intestine was the most common organ transplanted among cases (61%), and lung transplant was the most common in the control group (41%). Among cases, intra-abdominal infection was the most common site of infection (61%) whereas it was candidemia in controls (44%). Candida glabrata was the most common species in both groups (100% of cases and 50% of controls). Management involved source control maneuvers in 100% of cases and 96% of controls. Micafungin was used either alone or in combination for 2/3^rd of cases. Failure to clear candidemia occurred in 12.5% cases and 3.8% controls. Treatment failure for deep infection was seen in 8.5% cases and 2.9% controls. 30-day survival was similar between the 2 groups (82% cases and 89% controls). With regard to risk factors, significantly more case patients received antifungal therapy in the previous 90 days compared to controls (94% versus 63%, p=0.009), had a central venous catheter (100% versus 67%, p=0.002), or were administered parenteral nutrition (78% versus 13%, p<0.001). Recent rejection was more common in case patients, but the difference did not reach statistical significance (39% versus 17%, p=0.07). The proportion with recent surgery within 90 days was similar between the 2 groups (78% of cases versus 67% of controls). In multivariable logistic regression analysis, antifungal therapy in the previous 90 days (OR 14.6, 95% CI 2.1-307) and intestinal transplant (OR 9.9, 95% CI 2.3-55) were associated with increased odds of micafungin non-susceptible IC while lung transplant (OR 0.15, 95% CI 0.007-0.98) had lower odds of micafungin non-susceptible IC

*Conclusions: Antifungal therapy in the previous 90 days and type of organ transplanted were associated with micafungin non-susceptible IC. In these high-risk patients, our data may have implications on the choice of empiric antifungal therapy. The favorable outcomes observed likely reflect and underscore the importance of combined aggressive source control and medical therapy

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